Over View
Diabetes mellitus is mostly common endocrine disorder
The charateristic is by impairment of glucosa metabolism
There are two type of DM, type 1 and type 2
Type 1 is required insulin for treatment because of destruction of insulin-producing beta cells of the pancreas
Type 2 may be managed by involving oral drugs, diet and sometime insulin; type 2 because lack of sufficient insulin production, mostly this is call "Insulin resistance"
Diabetis mellitus can lead microvascular and macrovasvular complications, and large risk of cardiovascular disease
Microvascular complication included nephropathy, peripheral neuropathy and retinopathy
Macrovascular complications included peripheral vascular disease, cardiovacular disease such as stroke and myocardial infraction
Microvascular and Macrovascular change production of diabetic foot ulcers (Nadia;163)
Epidemiology
Diabetes is most commonly occuring endorine disease, 2.3 million in UK and 5% of population in America suffering for.
Type 1 is less common then type 2, accounting 10 - 20% of Diabetic diagnosis, and there is a strong genetic link type 1
Type 1 has a younger than type 2, most case diagnosed under 40 year and type 2 is associate with obesity and often association with hypertension, cardiovascular disease and dyslipideamias
Signs and Symptoms
Even type1 and type2 mostly dominant of are the same :
- increase thirst- fatique
- glycosuria
- blurred vision
- weight loss for type1
- present Diabetic Ketoacidosis (DKA) type1
- increase polyuria
- dehydration is caused by diuresis and vomitting which occurs as the body to lower high
blood level of glucoce and ketones, this leads to further vomitting, blurred vision,
confusion, dizziness, ketones in breath and eventually coma and possible death
Investigation
Diagnosing is refered WHO criteria diagnosing, they are :- a plasma glucose level 200 mg/dl (11.1 mmol/L)
- a fasting plasma glucose level 126 mg/dl (7.0 mmol/L)
- a plasma glucose level 200 mg/dl (11.1 mmol/L) 2 hours after ingestion 75 g anhydrous
glucose in Glucose Test Tolerance or Postprandial Plasma Glucose (GTT/PPG)
- Persons with fasting plasma glucose levels ranging from 110 to 126 mg per dL (6.1 to 7.0
mmol per L) are said to have impaired fasting glucose, while those with a 2hr PPG level
between 140 mg per dL (7.75 mmol per L) and 200 mg per dL (11.1 mmol per L) are said
to have impaired glucose tolerance.
- Both impaired fasting glucose and impaired glucose tolerance are associated with an
increased risk of developing type 2 diabetes mellitus. Lifestyle changes, such as weight
loss and exercise, are warranted in these patients. (anonymous,1997)
Recommendations for Diabetes screening of
asymptomatic person
- Patients 45 years of age or older ; repeat every three years
- Test before age 45; repeat more frequently than every three years if patient has one or
more of the following risk factors :
- Obesity : BMI more than or even 27 kg /m sequare
- Hypertensive : more than or even 140/90 mm Hg
- HDL Cholesterol level : more than or even 35 mg/dl (0.90 mmol per L)
- Triglycerida level : more than or even 250 mg / dl (2.83 mmol/L) (anonymous,1997)
Management
The aim of therapy is to manage the symptom of diabetes, reduced of secondary complications, avoid episodes of acute hyper and hypoglycaemia :
Type 1
- Type1 required the administration of exogonous insulin to manage their condition
- Insulin may be classified, as fast, intermediate and long acting, reflecting their onset and
duration of action
Type 1
- Type1 required the administration of exogonous insulin to manage their condition
- Insulin may be classified, as fast, intermediate and long acting, reflecting their onset and
duration of action
- Insulin regular is zinc insulin solution crystal with short acting insulin, administration by
subcutan or intravena in certainty condition, peak level reached in 2 hours after
administration. They are administered prior to meals and newer analogous type such as
insulin lispro and aspart, being given as a meal is commenced
- Intermediate-acting Insulin such as Isophane and lente insulin, achieve peak
concentration approximately 4-8 after administration and usually require twice daily
dosing
- Long acting Insulin such as glargine, determir insulin, have duration of activity
approcimately 24 hours may bi given once a day
Type 2
- Treatment is aimed to achieve HbA1c between 6.5% - 7.5%
- Initilal management involve life style intervention focused on diet, smoking, and exercise
- If this fails to achieve, drugs therapy is iniatiated. treatment option included the biguanida
metformin, sulfonylurea such as gliclazida and tolbutamid, meglitinida such as repaglinida,
thiazolidinedion such as rosiglitazone, and the glucosidase inhibtor acarbose
- The choice of initial therapy is usually made based on the person's mass body index
- The majority of type 2 diabetic are obese, and metformin is recommended in those with a
BMI more than 25 unless there is renal and impairment or intolerance, where a
sulphonylurea may be used
- If metformin is in ineffective sulphonylurea should be added. if this fails to provide control,
the patient should be reviewed by a specialist and the addition of insulin or a glitazone is
usually considered
- In those with a BMI less than 25 a sulphonylurea is usually the first line therapy, with
metformin added if target are not achieved
- Acarbose is usually only used for the treatment of resistant disease where there is
intolerance or contraindication to other drugs
achieve adequate control through appropriate diet without the need medications.
However all patients will benefit from better dietary control
- Meals should be at regular intervals. Carbohydrats should ideally have a low glycemics
index (e.g wholemeal pasta and bread) rather than be refined
- Patients should try to limit fat intake, increase fibre and eat at least five portions of fruit
and vagetable per day
- Other risk of cardiovasvular disease should managed where appropriate, such as
hypertension, dyslipideamias
- Over all early and intesive treatment is associated with decrease risk of complications of
diabetes
subcutan or intravena in certainty condition, peak level reached in 2 hours after
administration. They are administered prior to meals and newer analogous type such as
insulin lispro and aspart, being given as a meal is commenced
- Intermediate-acting Insulin such as Isophane and lente insulin, achieve peak
concentration approximately 4-8 after administration and usually require twice daily
dosing
- Long acting Insulin such as glargine, determir insulin, have duration of activity
approcimately 24 hours may bi given once a day
Type 2
- Treatment is aimed to achieve HbA1c between 6.5% - 7.5%
- Initilal management involve life style intervention focused on diet, smoking, and exercise
- If this fails to achieve, drugs therapy is iniatiated. treatment option included the biguanida
metformin, sulfonylurea such as gliclazida and tolbutamid, meglitinida such as repaglinida,
thiazolidinedion such as rosiglitazone, and the glucosidase inhibtor acarbose
- The choice of initial therapy is usually made based on the person's mass body index
- The majority of type 2 diabetic are obese, and metformin is recommended in those with a
BMI more than 25 unless there is renal and impairment or intolerance, where a
sulphonylurea may be used
- If metformin is in ineffective sulphonylurea should be added. if this fails to provide control,
the patient should be reviewed by a specialist and the addition of insulin or a glitazone is
usually considered
- In those with a BMI less than 25 a sulphonylurea is usually the first line therapy, with
metformin added if target are not achieved
- Acarbose is usually only used for the treatment of resistant disease where there is
intolerance or contraindication to other drugs
General Management
- Diet management is important both types of diabetes. Some patients with type 2 mayachieve adequate control through appropriate diet without the need medications.
However all patients will benefit from better dietary control
- Meals should be at regular intervals. Carbohydrats should ideally have a low glycemics
index (e.g wholemeal pasta and bread) rather than be refined
- Patients should try to limit fat intake, increase fibre and eat at least five portions of fruit
and vagetable per day
- Other risk of cardiovasvular disease should managed where appropriate, such as
hypertension, dyslipideamias
- Over all early and intesive treatment is associated with decrease risk of complications of
diabetes
Monitoring parameters
- Sign of secondary complications should be assessed through assessesment renal function,
blood pressure, urine dipstick testing for present protein, food review, eye test, wieght
and waist
- Change drugs therapy should be made if glycaemic control is unsatisfactory or the patient
is experiencing any drugs related problems
appropriately
- Indjection site should be rotated to avoid reaction, such as lipohypertropi
- If the patient is suffering from frequently hyper - hypoglycaemic episode, their regimen
should be reviewed and adjusted as necessary. It is usual for patient's insulin requirement
to increase with time
Metformin
- Many patients suffer GI complaint with metformin such as anorexia, diarrhoea, these may
be minimiced by gradually increasing the dose and taking it with food
- In some patients, the GI disturbance may be so severe as to prevent patients continuing
the drugs
- There is a risk of lactic acidosis, especially in those with renal or hepatic dysfunction, there
fore regular monitoring renal and liver fucntion is important
- Dose : three times one tablet 500 mg per day or two times one tablet 850 mg per day,
may be given when it takes food or after taking food
agents such as gliclazide are preferred
- Sulphonyourea may induced weight gain, so regular monitoring of weight is important
- dose : two times one tablet or three times one tablet per day defend on seriously disease
as swollen ankles and breathlessness should be looked for
- Glitazone may cause drugs-indused hepatotoxicity, so liver function should be assessed at
regular interval
- Full blood counts should also be performed as glitazones may induce anemia
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- Sign of secondary complications should be assessed through assessesment renal function,
blood pressure, urine dipstick testing for present protein, food review, eye test, wieght
and waist
- Change drugs therapy should be made if glycaemic control is unsatisfactory or the patient
is experiencing any drugs related problems
Insulin
- Patient's injection should be assessed regularly to ensure they are using insulin appropriately
- Indjection site should be rotated to avoid reaction, such as lipohypertropi
- If the patient is suffering from frequently hyper - hypoglycaemic episode, their regimen
should be reviewed and adjusted as necessary. It is usual for patient's insulin requirement
to increase with time
Metformin
- Many patients suffer GI complaint with metformin such as anorexia, diarrhoea, these may
be minimiced by gradually increasing the dose and taking it with food
- In some patients, the GI disturbance may be so severe as to prevent patients continuing
the drugs
- There is a risk of lactic acidosis, especially in those with renal or hepatic dysfunction, there
fore regular monitoring renal and liver fucntion is important
- Dose : three times one tablet 500 mg per day or two times one tablet 850 mg per day,
may be given when it takes food or after taking food
Sulphonylureas
- Unlike metformin, the sulphonylurea may cause hypoglycaemia, therfore short-acting agents such as gliclazide are preferred
- Sulphonyourea may induced weight gain, so regular monitoring of weight is important
- dose : two times one tablet or three times one tablet per day defend on seriously disease
Glitazone
- Glitazone may cause oedema, especially in those with cardiac failure, sign of oedema suchas swollen ankles and breathlessness should be looked for
- Glitazone may cause drugs-indused hepatotoxicity, so liver function should be assessed at
regular interval
- Full blood counts should also be performed as glitazones may induce anemia
editor by Iskani.,drs.,Apoteker
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- Bukhari,Nadia and David Kearney. 2009. Therapeutic. London. Pharmaceutical Press
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